Author Question: The nurse is evaluating the client in the hospital's postanesthesia care unit (PACU) and deter-mines ... (Read 58 times)

rachel9 · **on:** Jul 23, 2018

The nurse is evaluating the client in the hospital's postanesthesia care unit (PACU) and deter-mines that the Aldrete score is 8. Based on this assessment, the nurse anticipates that the client will:

1. Be sent to the intensive care unit
2. Be discharged back to his or her room on the nursing unit
3. Remain in the PACU until the score improves
4. Return to the operating room for surgical evaluation

Question 2

A client is in the postanesthesia care unit (PACU) recovering from a vagotomy and pyloroplasty. Which of the following is a normal expectation of the client in this stage of recovery?

1. Returned normal bowel sounds on auscultation
2. Pain that is relieved with noninvasive comfort measures
3. Voluntary bladder control and function
4. A subdued level of consciousness and neurological function

itsakadoozi · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 2
The client must receive a composite Aldrete score of 8 to 10 before being discharged from the PACU. The nurse may anticipate that the client with an Aldrete score of 8 will be discharged back to his or her room on the nursing unit. If the client's condition is still poor 2 to 3 hours after surgery (an Aldrete score below

, the health care provider may transfer the client to an intensive care unit. If the client's condition is still poor 2 to 3 hours after surgery (an Aldrete score below

, the health care provider may lengthen the client's stay in the PACU until the score improves. A client with an Aldrete score of 8 is unlikely to return to the operating room for surgical evalua-tion.

Answer to Question 2

ANS: 4
In the PACU the client is often drowsy. The effects of anesthetic agents subdue the client's level of consciousness and neurological function. Normally during the immediate recovery phase in the PACU, faint or absent bowel sounds are auscultated in all four quadrants. Clients who have had abdominal surgery may develop paralytic ileus, with a return of bowel sounds 24 to 48 hours lat-er. The acute incisional pain experienced in this stage of recovery is usually not relieved with noninvasive comfort measures but will require pharmacological measures of pain relief. Depend-ing on the surgery, a client may not regain voluntary control over urinary function for 6 to 8 hours after anesthesia.